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New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
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eLetters

Disruptive sleep patterns among junior doctors

Zain Ahmed, Junior doctor, Dartford and Gravesham NHS Trust
Ben Harman-Jones, Psychiatry trainee, Kent and Medway NHS and Social Care Partnership Trust
Aamer Sarfraz, Consultant Psychiatrist and Director of Medical Education, Kent and Medway NHS and Social Care Partnership Trust
01 October 2019

Last year, The College drew attention to the issue of fatigue among trainee psychiatrists in the survey: Supported and Valued? Staying Safe. We set out to examine the quality of sleep patterns among junior doctors undertaking night time on-call working in our Trust: Kent and Medway NHS and Social Care Partnership Trust.

Sleep quality after finishing a set of night on-calls was reported as ‘fairly bad’ in 39% and ‘very bad’ in 32%. The aforementioned survey commented on the importance of driving to junior doctors, who in psychiatry are uniquely expected to cover multiple sites while working on-call. In line with this, we found that 81% of our junior doctors drove home after their night on-calls, and as expected, in the week following a set of night on-calls, 71% had trouble staying awake while driving, eating and during social activities. Particularly worryingly, we found that during this period 32% used medicine to aid sleep, which due to potential variation in individual pharmacodynamics makes driving while fatigued even more dangerous.

This issue is particularly important now due to the impending threat to junior doctor’s working patterns posed by a no-deal Brexit. Safeguards provided by the European Working Time Directive would be lost overnight, and the already immense staffing pressures could be exaggerated due to a loss of skilled professionals from overseas, which our speciality is particularly reliant on.

For all these reasons, this issue has never been more important than now. We sincerely hope that another junior doctor will not come to serious harm or worse because of these issues, but urgent action to prevent this becoming a reality is clearly required.
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Conflict of interest: None declared

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Is it feasible to obtain patient feedback in Psychiatric Speciality trainee placements for professional development?

Sahan Wijayaweera, ST7 in General Adult and Old Age Psychiatry, Southern Health NHS Foundation Trust
25 September 2019

I have recently undertaken a project related to patient experience feedback at an individual level. Patient experience feedback is vital for quality improvement of services and professional development of doctors. It is a revalidation requirement of the General Medical Council for permanently employed doctors.1 As one of the domains of training schemes is to prepare trainees for Consultant role, it is important they experience patient feedback about their performance prior to taking on the role. During their time as a trainee they can receive support to help them manage the patient feedback that they receive.

Measuring the quality of service in any branch of medicine through patient experience with an individual doctor at any point in career is challenging to the doctor. It may be influenced by the physical and mental status of patient, issues arising during therapeutic alliance and socio-cultural characteristics of the doctor and the patient.2 Hence, there should be a system to prepare trainees at least from ST6 to deal with feedback and build up resilience to such situations.

Currently, there is no formalized system of obtaining patient/carer feedback for trainee doctors in the Health Education Wessex. The objective was to study the feasibility of obtaining feedback from patients in Older Persons Psychiatry Service with cognitive and mental impairment in a community setting via a questionnaire.

Using the the GMC’s recommended patient questionnaire for revalidation as a model

we tailor made a new questionnaire with support from a focus group. It was reviewed and refined by a local Carer’s Group and Older Persons Mental Health (OPMH) team. The sample comprised of new patients attending my (trainee’s) outpatient clinics and home visits during the period of 1st September to 30th November 2018. At the end of the consultation the doctor explained to the patients regarding the feedback questionnaire. Later, questionnaires were posted to the patients with a prepaid envelope along with their clinic letter. The replies were collected by a member of the administrative team who numbered them. The responses were processed by the doctor and a member of the administrative team to minimize bias.

There was a fair response with a total of 10 filled forms returned (66.66%) over a three month period. The feedback was positive and constructive. It also provided me with information to further develop my interactions with patients and their carers.



This project demonstrates the feasibility of obtaining patient feedback on trainee consultations within a short time frame. Also it does demonstrate the value of getting focus group involvement when designing such tools in order to make them more user friendly to their target audience. There is scope to extend this to other trainees within the Psychiatry Higher training scheme in order to gather more data and feedback about its effectiveness for trainees.

Dr Sahan Wijayaweera, ST7 in General Adult and Old Age Psychiatry, Southern Health NHS Trust, UK. Email: sahan.wijayaweera@nhs.net.

Dr Balaji Wuntakal, Consultant in Old Age Psychiatry, Solent NHS Trust, UK.

1. Academy of Medical Royal Colleges, Revalidation what it means for us. Available from: http://www.aomrc.org.uk/wp-content/uploads/2017/07/Revalidation_what_it_means_for_us_all_0617-1.pdf

2. D A. Barker, S S. Shergill, I Higginson and M W. Orrell. Patients' Views Towards Care Received from Psychiatrists, The British Journal of Psychiatry. 1996;168:(5): 641-646. Available from: https://doi.org/10.1192/bjp.168.5.641

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Conflict of interest: None declared

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Abuse of Psychiatry in Iran

Giuseppe Spoto, former Visiting Consultant , Priory Hospital
02 August 2019

Sir,

In the past the Royal College of Psychiatrists has been very active challenging abuse in relation to Psychiatry and I distinctly remember for example Dr S Bloch and others successfully exposing abuse of Psychiatry in the former Soviet Union in the 1970’s.

Why is the College silent about the antediluvian treatment recently endured by Nazanin Zachary-Radcliff in Iran ?

Simply by exposing such barbaric practice on the international stage and using its authority the College may succeed where others have failed, namely her immediate release.
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Conflict of interest: None declared

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to Abuse of Psychiatry in Iran


Dr Andrew Camden

Andrew Camden, ST6 in General Adult Psychiatry, South London and the Maudsley NHS Foundation Trust
14 May 2019

Queering the Mental Health Model

I have been involved in a project run by the artist La JohnJoseph (JJ), on “Queering the Mental Health Model”. JJ’s interest in the area was sparked by their experience visiting an ex-partner who was detained on a psychiatric ward, where “queerness” often seemed to be conflated with illness by ward staff. JJ observed the difficulty of maintaining individuality in the confines of the ward environment; they noted that an attempt to do so was at times interpreted by staff as a sign of pathology.

JJ led 10 sessions over 12 months around the UK, to which people who self-identify as queer were invited to talk about their experience of psychiatric services. There was a general sense that people felt poorly understood outside specialist services, which are difficult to access; participants described a sense of having to fight their way through the system. There was, however, a multitude of positive feedback from people who had felt able to access a small number of appropriate specialist services.

“Queer” tends to be used now as an umbrella term to describe non-cis or non-heterosexual people. Historically derogatory, from the early 1990s queer was reclaimed as a self-affirming term, originally by the gays rights movement. Queer challenges our tendency towards conventional categorization into defined groups and helps remind us of individuality and the diversity of identity. As part of the LGBTQ community, it is known that people who self-identify as queer suffer higher rates of mental distress than the population at large (1). JJ’s project will shed some light on the reasons for this.

There is a dearth of literature on this topic. A literature search by Reay House Library (based at Lambeth Hospital in London) on the “experience of psychiatric/mental health services of people who self-identify as queer” found a total of 33 articles, of which 4 were by UK authors. None of these has a specific focus on people who identify as queer; they describe experiences of the UK LGBTQ community in general. Two articles have an historical focus. Hughes et al have published two recent articles, one looking at the experiences of LGBTQ youth (ages 16-25) of suicidality and help-seeking (2) and one on the perceptions and practice of mental health staff of this group (3) . There is clearly scope to further examine the experience of psychiatric services of people who identify as queer, to help inform how these might better meet demand and reduce feelings of distress and marginalization.

JJ’s performance piece based on their experiences on the psychiatric ward, “A Generous Lover”, will tour the UK in September. There is further information at www.lajohnjoseph.com.

References

1. McDermott E, Hughes E, Rawlings V. Mental health staff perceptions and practice regarding self-harm, suicidality and help-seeking in LGBTQ youth: Findings from a cross-sectional survey in the UK. Issues in Mental Health Nursing, 2018;39(1): 30-36

2. McDermott E, Hughes E, Rawlings V. Norms and normalization: understanding lesbian, gay, bisexual, transgender and queer youth, suicidality and help-seeking. Culture, Health & Sexuality 2018;20(2): 156-172

3. McDermott E, Hughes E, Rawlings V. Mental health staff perceptions and practice regarding self-harm, suicidality and help-seeking in LGBTQ youth: Findings from a cross-sectional survey in the UK. Issues in Mental Health Nursing, 2018;39(1): 30-36

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Conflict of interest: None declared

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Still room for improvement: Standardisation of clinical correspondence and experience in a rural crisis and home treatment service.

Daniel Robinson, Foundation Year 2 Doctor, Cumbria Partnership NHS Foundation Trust
Samuel Dearman, Consultant Psychiatrist, Cumbria Partnership NHS Foundation Trust
27 March 2019

The communication of important clinical information in the management of our patients, continues to occur in the large part through clinical letters, electronic or otherwise. Poor letter writing which misses important information and does not highlight key considerations leads to sub-optimal care. This is certainly true in the crisis and home treatment team environment, where patients are presenting with increased levels of risk and are often discharged solely to the care of their general practitioner. Unfortunately, omission of information often occurs. A study of letters from mental health services in London found a mismatch between what GPs felt they needed to know and what was being included where for example, only 17% of the letters in this study included a diagnosis (1). Evidence suggests that structured letter formats take no longer to read, are preferred by GPs, improves comprehension of letters and reduces the risk of omission of information by the author and reader (2).

Anecdotally, we observed variation in our medical correspondence to our general practitioner colleagues and thus undertook a quality improvement project looking at improving the quality and consistency of letters produced by our team. This project was used as a developmental opportunity for one of our trainees under consultant supervision to learn more about the quality improvement process and to solidify the trainees understanding of the psychiatric history, MSE and risk assessment as core psychiatric competencies.

We determined clinical letter standardisation by including widely recognised components of the psychiatric history and the requirements of our service operational policy. We included diagnosis with ICD 10 code, formulation, risk assessment, plan and capacity to consent to the care plan.

In phase one, using our standardised template we examined all existing letters from a randomly selected period (January and February 2018) of existing letters within the service. In these, 44% included past psychiatric history, 38% included past medical history, 19% included personal history, and forensic history was included in none. Mental State Examination also contained omissions with 62% documenting speech, 56% documenting thoughts and 63% documenting perception. From the perspective of a crisis and home treatment service it was noteworthy that history of self-harm was included in 38% of letters, risk of suicide 81%, harm to others in 50%, risk to dependants in no letters, and risk of self-neglect and vulnerability documented in 25% each.

The standardised letter templates was developed collaboratively, communicated and agreed with all medical practitioners and all grades in the service. It was universally implemented and allowed to be used for 6 months. After this we again assessed the content of medical letters, including all those produced for a second randomly selected period (September and October 2018). A significant improvement was seen. Following implementation of the template all aspects improved: Past psychiatric history 96%, past medical history 92%, forensic history 67%. It was reassuring that documented risk of suicide increased to 100%, self-harm to 96%, harm to others 96%, to dependants 80%, of vulnerability 84%, and in the mental state examination speech 92%, thoughts 100%, and perception 96%.

Overall our results demonstrate that standardisation of doctor’s letters continues to be an area for improvement within psychiatric services, but that relatively simple methods and collaborative efforts can lead to significant quality improvements. We hope our approach warrants consideration from the wider pool of colleagues as we meet our duties to improve the quality of services (3) and especially commend engaging trainees in the process as a learning opportunity in an attempt to add as much value as possible.

References

1. Nilforooshan R, Weston L, Sachdeva D, Rampes H, Warner J, Nasri M. What information do general practitioners expect in letters from mental health services? London Journal of Primary Care: Abingdon; 2009. p. 43-5.

2. Melville C, Hands S, Jones P. Randomised trial of the effects of structuring clinic correspondence. Archives of Disease in Childhood. 2002;86(5):374-5.

3. Good Medical Practice (2013). www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

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Conflict of interest: None declared

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Results of a survey on the views of psychiatrists on physician associates and physician associate students

Sarah Jones, Psychiatry Registrar ST6, Sheffield Health and Social Care NHS Foundation Trust
Reem Abed, Consultant Psychiatrist, Sheffield Health and Social Care NHS Foundation Trust
Helen Crimlisk, Consultant Psychiatrist, Sheffield Health and Social Care NHS Foundation Trust
27 March 2019

The Mental Health Workforce Plan (1) names physician associates (PAs) as a proposed new role in mental health. The Royal College of Psychiatrists is drafting a paper on PAs and proposes a target of 10% of graduates to be employed within psychiatric services (personal communication). There is little data on the views of psychiatrists about this. An online survey was circulated in the General Adult Psychiatry newsletter in June 2018. There were 87 responses.

Of 19 consultants, 7 felt they did not have a good understanding of what a PA is and 6 agreed with the statement “I object to the concept of PAs.” The majority of these respondents reported little contact with PAs and PA students.

16/32 respondents were not confident about PA student placement learning objectives and signing students off. Confidence was higher at teaching and assessing PA students. Consultant respondents commented on a lack of specificity in the PA syllabus regarding mental health learning objectives, a low level of knowledge and poor awareness amongst PA students of their learning needs.

43/63 (68%) respondents felt that PAs could make a positive contribution to the mental health workforce. Most respondents felt that PAs could perform physical health checks, ECGs and blood tests (63%), clerk in new patients (42%) and perform mental state examinations (39%). Undertaking specialist clinics, seclusion reviews and leading an MDT were felt to be unsuitable for PAs with 40%, 39% and 65% of respondents respectively indicating they believed they could not undertake these tasks. 4 respondents made comments about the need for PAs to complete some form of post graduate qualification in psychiatry. This is commonplace in the United States, where the PA role has been embedded in the workforce since 1965.

The Faculty of Physician Associates is seeking statutory registration for PAs (2). 16/36 respondents indicated that lack of regulation made them less willing to teach PA students and 27/58 respondents indicated that lack of regulation made them less likely to welcome PAs to the workforce. Respondents highlighted concern about patient safety and accountability in the absence of statutory registration. Consultation on a bill for regulation of PAs is underway (3).

A previous survey of UK consultants identified the inability to prescribe and the requirement for consultant supervision as issues that limited PAs’ effectiveness (4). In our survey, consultant psychiatrists were divided about this. 5 stated the need to provide consultant supervision would make them more likely welcome PAs into the workforce, 6 felt it made no difference and 8 felt it made them less likely. 16 out of 55 participants rated themselves as less likely to welcome PAs to the workforce due to their inability to prescribe.

These results point towards a lack of understanding about PAs and how they could support psychiatric teams. Case studies of PAs working in psychiatric teams (5) may help, as well as increasing exposure of psychiatrists to PAs. University tutors must ensure that clinicians understand the learning objectives and expected attainment level required for placement sign off.

References

1. Health Education England. Stepping forward to 2020/21: the mental health workforce plan for England [Internet]. 2017 [cited 2019 Feb 9]. Available from: https://www.hee.nhs.uk/sites/default/files/documents/Stepping forward to 202021 - The mental health workforce plan for england.pdf

2. Faculty of Physician Associates. Who are physicians associates? [Internet]. [cited 2019 Feb 7]. Available from: https://www.fparcp.co.uk/about-fpa/Who-are-physician-associates

3. www.parliament.uk. Physician Associates (Regulation) Bill 2017-19 — UK Parliament [Internet]. [cited 2019 Feb 7]. Available from: https://services.parliament.uk/bills/2017-19/physicianassociatesregulation.html

4. Williams LE, Ritsema TS. Satisfaction of doctors with the role of physician associates. Clin Med J R Coll Physicians London. 2014;14(2):113–6.

5. Gill K, Kauser S, Khattack K, Hynes F. Physician associate: new role within mental health teams. J Ment Heal Training, Educ Pract [Internet]. 2014;9(2):79–88. Available from: http://www.emeraldinsight.com/doi/abs/10.1108/JMHTEP-08-2013-0029

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Conflict of interest: None declared

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Scottish Survey of Prescribing Benzodiazepines in Benzodiazepine Dependence

Michael William Turner, ST5 General Adult Psychiatry, NHS Grampian
Seonaid Anderson, Consultant Addiction Psychiatrist, NHS Grampian
20 November 2018

It is estimated that 0.69% of patients at GP surgeries in the UK are classed as long term benzodiazepine users [1]. As there appears to be a steady increase in the length of benzodiazepine prescribing, it may be that benzodiazepine dependence is becoming a larger problem [2]. The population of individuals who have become dependent on benzodiazepines is clearly diverse, from young multi-substance abusers who may purchase diverted supplies, to the elderly who may have been on a night time dose for over a decade. Its individuals from the former group that often cause anxiety in practitioners, where the quantity and type of benzodiazepine consumed is often unknown.

We created a survey composed of ten questions in an attempt to assess specialist clinician’s views on benzodiazepine prescribing in benzodiazepine dependence, as well as examining people’s practices in this situation. The survey was distributed to 119 recipients on the Scottish Association of Addictions Specialists’ mailing list. The survey was distributed on 1st August 2018, and closed on Friday 17th August. For questions where an open text response was requested, answers were reviewed and grouped together in re-occurring themes. Results were presented to the Scottish Association of Addiction Specialists on 7th September 2018 in Stirling.

There was an overall 51.0% response rate. 53.3% of responders were consultant psychiatrists. 20% were specialty doctors and the remainder were general practitioners, associate specialists, and trainee psychiatrists. 27.9% worked for NHS Greater Glasgow and Clyde, followed by 13.1% working in NHS Grampian. Responses were also received from people working in NHS Ayrshire and Arran, NHS Forth Valley, NHS Lothian, NHS Highland, NHS Tayside, NHS Borders, NHS Fife and NHS Lanarkshire. There were also a few responses from retired and locum practitioners.

78.7% of people who responded would prescribe benzodiazepines in benzodiazepine dependence, and 21.3% would not. Those who would not prescribe were distributed across 8 different health boards, with 7 consultants, 3 specialty trainees/registrar psychiatrists, 2 specialty doctors and one general practitioner. Of those who would prescribe benzodiazepines, 89.8% would require a history, 69.4% a drug screen and 57.1% a drug use diary. Other requirements mentioned were a motivation to change (22.4%), good engagement with services (18.4%) and a diagnosis of benzodiazepine dependence (8.3%). 100% favoured Diazepam as their benzodiazepine of choice, if starting in those with benzodiazepine dependence.

52.0% of people using benzodiazepines in benzodiazepine detox opted for a maximum starting dose of 20 to 30mg Diazepam equivalent. 6.0% would start 0 to 10mg and 16.0% would start 10mg to 20mg. 24.0% would use doses of 30 to 40mg. 1 participants would use up to 80mg, but stated that this was only in an inpatient context.

In terms of initial dispensing 76.0% would prescribe daily dispense. 12.0% opted for consume on premises, 8.0% weekly dispense, and no-one would prescribe monthly. 1 person said they would only provide as an inpatient and another said they would align this with their methadone dispensing.

70.0% would be prescribing with the intent to reduce. 6.0% prescribe with the intent of maintenance prescribing. 24.0% preferred to document their own practice, with the majority of these individuals stating it depended on the clinical picture.

All participants - those who prescribe and those who don’t - were asked what guidelines they used for people in benzodiazepine dependence. 49.0% primarily used local guidelines, 31.4% used the “orange” guidelines (Drug misuse and dependence: UK guidelines on clinical management), and 19.6% used either a combination or other resources such as the Royal College of General Practitioner guidance, British Association for Psychopharmacology guidelines, Ashton manual, the Maudsley or just clinical experience.

The last question asked what other treatments you would consider in benzodiazepine dependence. 56% of responders to this question suggested psychological input. Several replies however noted that referrals were often rejected, and that at times patients failed to engage. 34% mentioned psychosocial interventions and 26% noted alternative medications. 12% suggested that the underlying illnesses should be treated appropriately, 4% would optimise opiate replacement therapy and 4% would provide psychoeducation.

The practice of prescribing benzodiazepines, as well as choosing not to, was not limited to a particular health board and can therefore not be

explained by local policy. Those who did not prescribe benzodiazepines in this situation came from eight separate health boards. They were also a mix of professions and grades, including a GP, Consultants, specialty doctors and speciality trainees/specialist registrars. Experience can differ between these titles, however it can be assumed that since different consultants disagreed on whether benzodiazepines should be prescribed, experience may not be relevant to this decision.

It is clear that opinion is divided when it comes to prescribing benzodiazepines in benzodiazepine dependence. Unfortunately, clinicians feel that when it comes to practice in this area, there is a distinct lack of evidence. This obviously contributes to a variation in practices. Some may believe that not prescribing, with a lack of evidence, would be the most medico-legally responsible. However it may be that this attitude is avoiding benzodiazepine dependence rather than engaging with it, and with some guidance supporting benzodiazepine prescribing in dependence this issue can be tackled with more confidence.

1 Davies J, Rae TC, Montagu L. Long-term benzodiazepine and Z-drugs use in the UK: a survey of general practice. Br J Gen Pract, 17 July 2017.

2 J.C. Farias, L. Porter, S. McManus, et al. Prescribing patterns in dependence forming medicines. Public Health Research Consortium, London, 2017.
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Conflict of interest: None declared

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Latest Developments in ADHD

Dr Mukesh Kripalani , Frcpsych, Rcpsych
12 October 2018

Latest updates on ADHD 2018

Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) remains a controversial area for clinicians and patients across the world and the UK, despite evidence of effective treatment options and the likelihood of lives being changed for the better.

The National institute for health and care excellence (NICE) in the UK, have recommended interventions since 2006 and recently updated its latest guidance on diagnosis and management in March 2018 (https://www.nice.org.uk/guidance/ng87). They have made certain changes to past recommendations which include a suggestion of using Elvanse as first line in adult clients and introducing new safeguards in terms of specific cardiovascular assessment requirements in certain circumstances.

The prevalence of this condition varies across the world and one estimate suggest 5% of school-age children could suffer from the same with a significant cost burden to society (https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30269-4/fulltext). With persistence of ADHD symptoms estimated in to adulthood to be about 60% (https://newsroom.wiley.com/press-release/journal-child-psychology-and-psychiatry/study-estimates-adhd-symptom-persistence-adult ), it is imperative the clients are supported and clinicians are familiar with the phenotype and able to appropriately manage the significant co-morbidity that exists with ADHD/ADD (http://adhd-institute.com/burden-of-adhd/epidemiology/comorbidities/ ).

In a recent article by Sudha Raman et al in the Lancet, trends in attention-deficit hyperactivity disorder medication use was explored in 13 countries and one Special Administrative Region (DOI: https://doi.org/10.1016/S2215-0366(18)30293-1). They noted the prevalence of ADHD medication use among children and adults increased over time in all countries and regions, but large variations in ADHD medication use in multiple regions exist. They recommended evidence-based guidelines need to be followed consistently in clinical practice and Samuele Cortese and Daniel Cogill (https://ebmh.bmj.com/content/early/2018/10/09/ebmental-2018-300050) suggesting no increase in prevalence rates if standard criteria are used.

In a major lancet article (https://doi.org/10.1016/S2215-0366(18)30269-4) Samuele Cortese and co, looked at the comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults via a systematic review and network meta-analysis.

Summary:

I take this opportunity to highlight that pharmacological interventions are safe and is well tolerated across the world and use of stimulants is gradually increasing across the globe. The risks with stimulants medication are usually hyped up but it is exceptionally safe though the risk of diversion remains (https://www.sciencedirect.com/science/article/pii/S0890856709620815 ). The latter could be minimised easily by close supervision and use of long acting stimulants. It is important clinicians recognise this phenotype and direct clients to help as soon as possible as early intervention can change the trajectory of life (https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-99 ). The effect sizes clearly demonstrate benefits and the NICE guidelines seem to be consistent with latest meta analysis.

Of course there are co-morbid conditions co-existing which can mask the presence of ADHD and the fact of getting prescribed stimulants is difficult in certain situations to accept.

Hence instead of vilifying ADHD, we should encourage both clients and clinician to embrace the need for immediate treatment (biological, psychological and social) and hence improve outcomes for the future and help clients reach their full potential (https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-99 )

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Trials and Tribulations of S49 orders

Ilyas Mirza, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
Mukesh Kripalani, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
12 October 2018

The Mental Capacity Act, 2005 (MCA, 2005) is an Act of the Parliament, applying to England and Wales,that provides a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves (MCA, 2005). Under section 49 (pilot order) of the MCA 2005, launched in 2016, the Court of Protection can order reports from NHS health bodies and local authorities, when it is considering any question relating to someone who may lack capacity and the report must deal with ‘such matters as the court may direct’. This change has caused significant ethical challenges for psychiatrists.

With regard to professional implications, Section 49 reports require an opinion, which according to the British Medical Association (BMA) and the General Medical Council (GMC) guidance this falls under expert witness work. The recent Pool Judgement is a reminder that the GMC is likely to consider fitness to practice is impaired if a doctor acts outside what is considered their scope of work (Pool v General Medical Council[2014]). The order is usually accompanied by an instruction letter containing legal precedents and a bundle sometimes containing conflicting assessments. Responding to such instructions require medico-legal training and experience in giving opinions to complex questions such as capacity to consent to sex, or consent to drink. We would argue that there is blurring of boundaries between expert and professional witness. There is a need to clarify what legal safeguards that are in place for the author of Section 49 reports, if their opinion is challenged, as it was in the Pool case.

In relation to patient care, the introduction of an automatic right to a medico-legal report, which was previously funded from elsewhere has shifted the cost on to the NHS. Given mental health services are still block funded; more work without additional funding leads to dilution of quality of care elsewhere in the system, hence affecting patient care. Lack of parity of esteem between physical and mental health funding makes this work an onerous burden. Increased workload without remuneration has an adverse effect on staff morale, thereby influencing recruitment and retention within an already struggling NHS.

There is an urgent need to quantify impact on these orders on services. The Royal College of Psychiatrists, working together with NHS England and the BMA, need to define medico legal work could be safely done within existing resource. Moreover, the BMA, GMC, the College and NHS Employers need resolve the discrepancy between what is considered expert witness work by regulatory bodies, being framed as normal NHS work by the Court of Protection (GMC, 2013). Legal safeguards need to be in place if NHS professionals become subject to legal challenge e.g. from an aggrieved solicitor. Consideration needs to be given to a fresh legal challenge if it is evident that this pilot order is affecting patient care.



References

Court of Protection Transparency Pilot: Case management S.49 pilots extension. 27th July 2017. Courts and Tribunal Judiciary

https://www.judiciary.uk/publications/transparency-pilot-case-management-s-49-pilots-extension/

General Medical Council (2013) Good medical practice London, GMC

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/acting-as-a-witness/acting-as-a-witness-in-legal-proceedings

Mental Capacity Act (2005) Code of Practice (2007) London: TSO.

https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

Pool v General Medical Council(2014) EWHC 3791 Admin.

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Choose Psychiatry, Continue Psychiatry

Andrew Howe, ST 4 in General Adult Psychiatry, South London and Maudsley NHS Foundation Trust
Vivienne Curtis, Consultant Psychiatrist
13 September 2018

Could improving oncall experience be the key to trainee retention?

Alongside encouragement to “Choose Psychiatry” we need to consider retention and “Continuing Psychiatry”. A recent survey by the Royal College 1 found that management on-call work was affecting morale so much that some trainees considered resignation. The same report commented on a high attrition rate between core and higher training, citing on call issues as a factor. Out of hours work is a challenging part of working in healthcare. Unsocial working hours can put a strain on the work life balance2, particularly with those who have families.3 The recent junior doctor strikes and new contract highlighted the value junior doctors place on appropriate management of on call work4 and GMC NTS results often highlight difficulties with out of hors working. With psychiatry recruitment in its present state and the concerted effort to increase applications to training via “Choose Psychiatry”, the nature of the on call experience may be the key to ensuring trainee retention. It is important, therefore, to ensure that experience on call is positive, supported and reflects training goals. We would suggest that the involvement of junior doctors in service design and restructure helps to secure this.

This approach was taken within our trust (South London and Maudsley NHS Foundation Trust) during the creation of a new service, the Centralised Place of Safety. This six-bedded unit was opened in June 2017. It is staffed by a dedicated MDT 24 hours and seven days a week. It accepts section 136/135 patients as part of the South London Crisis care pathway. Given its out of hours operation, an on-call medical staffing rota had to be created. The trust involved junior doctors in this process in collaborative way, through discussion with trainee committees and representatives to ensure their educational needs were met. An emphasis was put on face to face supervision by higher trainees with core trainees. Core trainees also had a clearly defined role within the MDT. A subsequent survey of trainees found that they preferred their on-call work in the place of safety compared to other locations5. A quote from the survey of particular note was “I would not want to qualify as a registrar without having had such experience’.

Choice of training scheme is multifactorial and improving on call experience maybe a small but important factor. We feel our service and its design process represent a good example of how to meet trainees needs and, thus, reinforces the need for consideration of trainee experience when planning out of hours rotas. We would argue that retention needs to be prioritised as much as recruitment if the gains of the “Choose Psychiatry” campaign are to be maintained.

1. Till A, Milward K, Tovey M, et al. Supported and Valued? A trainee-led review into morale and training within psychiatry. London, 2017.

2. Karhula K, Puttonen S, Ropponen A, et al. Objective working hour characteristics and work–life conflict among hospital employees in the Finnish public sector study. Chronobiol Int 2017; 34: 876–885.

3. Tucker P, Brown M, Dahlgren A, et al. The impact of junior doctors’ worktime arrangements on their fatigue and well-being. Scand J Work Env Heal 2010; 36: 458–465.

4. Tucker P, Byrne A. The new junior doctors’ contract: an occupational health and safety perspective. Occup Med (Chic Ill) 2016; 66: 686–688.

5. Howe A, Curtis V. What is the educational benefit of being on call ? A review of the on-call experience of psychiatry trainees in a new health based Place of Safety. In: Royal College of Psychiatrists International Congress. Brimingham, 2018.

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Conflict of interest: None declared

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